Dysautonomia: an Explanation for the Medically Unexplained?

Objective: To identify dysautonomia as a collection of conditions with variable presentation that may be mistaken for medically unexplained symptoms. Methods: Case series. Results: Tilt table testing and 24 h electrocardiographic monitoring provided useful diagnostic tools to confirm the diagnosis. Conclusion: A greater awareness and recognition of the disorders that result from dysautonomia and recognition of the disability that results from these disorders will improve patients’ quality of life.

Acute Cholecystitis as a Complication After Colonoscopy: A Case Report and Literature Review

Acute cholecystitis after colonoscopy is a rare event, with less than 10 cases described in the literature. We report the case of a male patient with silent gallstones who underwent colonoscopy for follow-up of his Crohn’s disease. The colonoscopy revealed erosions in the terminal ileum, from which biopsies were taken. A sessile polyp 4 mm in diameter at the recto-sigmoid junction was also removed. Less than 24 h after the colonoscopy, the patient complained of upper right quadrant pain, nausea and vomiting. Based on the clinical findings, laboratory data and ultrasonography, we diagnosed acute cholecystitis and excluded any complication after the colonoscopy. Laparoscopic cholecystectomy was performed and the patient was discharged.

A Painless Thoracic Aortic Dissection

Thoracic aortic dissection (TAD) has a very high mortality rate and is often missed due to the atypical presentation of patients. We present a case of a man with chronic hypertension, atrial fibrillation (AF) (on regular warfarin) and a previous endovascular aneurysm repair (EVAR), who presented with dyspepsia and was incidentally found to have a ruptured distal thoracic aneurysm on imaging with no obvious clinical signs on examination, nor abnormalities on admission chest x-ray (CXR).

Increasing Skin Pigmentation Following Severe Head Trauma: All That Glitters Is Not Gold!

We report the case of a 67-year-old man who was admitted to our Intensive Care Unit because of traumatic brain injury. During his prolonged hospitalization, gradual darkening of the skin all over his body was observed. An excess corticotropin (ACTH) production syndrome was considered. The patient’s hormone study showed high levels of ACTH (978 pg/ml) with normal cortisol levels. Extensive clinical and laboratory investigations revealed adenocarcinoma of the colon, which was likely the site of the ectopic ACTH production. This is a very rare manifestation of paraneoplastic syndrome during the course of colon adenocarcinoma. The most important feature of this case report is that this rare syndrome was accidentally discovered, in a patient hospitalized for unrelated reasons, by simple clinical investigation.

A Case Against Fancy Decorated Drinks: Multi-Organ Failure After Drinking a Mojito Cocktail

We present the first case of gastro-intestinal perforation caused by a mint twig decorating a cocktail drink. A 76-year-old man was enjoying his Mojito cocktail on a cruise ship near Mexico when he accidently swallowed a mint twig, resulting in ileum perforation. This led to a cascade of events, eventually resulting in life-threatening multi-organ failure. Given this rare but potentially severe complication and the increasing popularity of decorated drinks, a less ‘fancy’ presentation for cocktails and similar drinks may be warranted.

Paradoxical Deterioration During Anti-Tuberculous Therapy in Non-HIV-Infected Patients with Pleural Tuberculosis: A Pragmatic Approach

We report a case of paradoxical deterioration. A male patient diagnosed with pleural tuberculosis, but who was not infected with human immunodeficiency virus (HIV), experienced clinical deterioration 3 weeks after the initiation of anti-tuberculous treatment. After other diagnoses were ruled out, a paradoxical response to treatment was established and the patient was started on systemic corticosteroids. Paradoxical response to treatment should be considered in patients with clinical deterioration after they start on anti-tuberculous treatment.

A Rare Presentation of Leptospirosis

Leptospirosis has a wide spectrum of clinical manifestations. Acute renal failure, an important complication, generally involves interstitial and tubular damage. We describe the case of a 42-year-old man who was admitted with fever, back pain and periorbital oedema. He had hypertension, thrombocytopenia, acute renal failure, hypoalbuminaemia, hypertriglyceridaemia and proteinuria >4.00 g/l. The renal biopsy showed mesangioproliferative glomerulonephritis. Due to the epidemiological context and clinical picture, ceftriaxone was started with rapid clinical improvement. Blood PCR for leptospira came back positive. The presentation of leptospirosis as nephrotic syndrome is rare and this diagnosis should be considered before performing a renal biopsy.

Simultaneous Acute Pulmonary Embolism and Isolated Septal Myocardial Infarction in a Young Patient

We report here the case of a young patient with a simultaneous isolated septal myocardial infarction (MI) and pulmonary embolism (PE). The aim was to describe a rare clinical entity and to explain why these two pathologies were present at the same time in a young patient.
 A review of literature was established. An interventional cardiologist, an interventional radiologist and a lung specialist were consulted. The diagnostic workup revealed only heterozygous Factor Leiden V mutation. This presentation was probably fortuitous, but worth reporting to our opinion.

Behind Recurrent Thromboembolic Events

We describe the case of a 68-year-old man, who presented with an ischemic stroke due to cardiac embolization related to mitral valve endocarditis. Blood cultures were always negative and post-operative valve histology did not show microorganisms. The patient also presented further recurrent peripheral embolic events. These clinical aspects were the first sign of a pancreas adenocarcinoma, which was only diagnosed in the clinical autopsy. In conclusion, these clinical findings of recurrent thromboembolic events with no microorganisms isolated suggests the diagnostic of a marantic endocarditis.

Geological Evolution of Coastal and Marine Environments off the Campania Continental Shelf Through Marine Geological Mapping - The Example of the Cilento Promontory

The geological evolution of coastal and marine environments offshore the Cilento Promontory through marine geological mapping is discussed here. The marine geological map n. 502 “Agropoli,” located offshore the Cilento Promontory (southern Italy), is described and put in regional geologic setting. The study area covers water depths ranging between 30 and 200 m isobaths. The geologic map has been constructed in the frame of a research program financed by the National Geological Survey of Italy (CARG Project), finalized to the construction of an up-to-date cartography of the Campania region. Geological and geophysical data on the continental shelf and slope offshore the southern Campania region have been acquired in an area bounded northward by the Gulf of Salerno and southward by the Gulf of Policastro. A high-resolution multibeam bathymetry has permitted the construction of a digital elevation model (DEM). Sidescan sonar profiles have also been collected and interpreted, and their merging with bathymetric data has allowed for the realization of the base for the marine geologic cartography. The calibration of geophysical data has been attempted through sea-bottom samples. The morpho-structures and the seismic sequences overlying the outcrops of acoustic basement reported in the cartographic representation have been studied in detail using single-channel seismics. The interpretation of seismic profiles has been a support for the reconstruction of the stratigraphic and structural setting of the Quaternary continental shelf successions and the outcrops of rocky acoustic basement in correspondence to the Licosa Cape morphostructural high. These areas result from the seaward prolongation of the stratigraphic and structural units, widely cropping out in the surrounding emerged sector of the Cilento Promontory. The cartographic approach is based on the recognition of laterally coeval depositional systems, interpreted in the frame of system tracts of the Late Quaternary depositional sequence.

Aflatoxin B1 and M1 Degradation by Lac2 from Pleurotus pulmonarius and Redox Mediators

Laccases (LCs) are multicopper oxidases that find application as versatile biocatalysts for the green bioremediation of environmental pollutants and xenobiotics. In this study we elucidate the degrading activity of Lac2 pure enzyme form Pleurotus pulmonarius towards aflatoxin B1 (AFB1) and M1 (AFM1). LC enzyme was purified using three chromatographic steps and identified as Lac2 through zymogram and LC-MS/MS. The degradation assays were performed in vitro at 25 °C for 72 h in buffer solution. AFB1 degradation by Lac2 direct oxidation was 23%. Toxin degradation was also investigated in the presence of three redox mediators, (2,2′-azino-bis-[3-ethylbenzothiazoline-6-sulfonic acid]) (ABTS) and two naturally-occurring phenols, acetosyringone (AS) and syringaldehyde (SA). The direct effect of the enzyme and the mediated action of Lac2 with redox mediators univocally proved the correlation between Lac2 activity and aflatoxins degradation. The degradation of AFB1 was enhanced by the addition of all mediators at 10 mM, with AS being the most effective (90% of degradation). AFM1 was completely degraded by Lac2 with all mediators at 10 mM. The novelty of this study relies on the identification of a pure enzyme as capable of degrading AFB1 and, for the first time, AFM1, and on the evidence that the mechanism of an effective degradation occurs via the mediation of natural phenolic compounds. These results opened new perspective for Lac2 application in the food and feed supply chains as a biotransforming agent of AFB1 and AFM1.

Il contributo dell’Unione europea all’affermazione dello stato di diritto nella comunità internazionale

This thesis is aimed at analysing EU external relations from the perspective of the promotion of the rule of law in order to evaluate the effectiveness and consistency of its action within the international community. The research starts with an examination of the notion of the rule of law from a theoretical point of view. The first chapter initially describes the historical-political evolution of the establishment of the notion of the rule of law. Some of the most significant national experiences (France, the UK, Germany and Austria) are discussed. Then, the focus is put on the need to propose interpretations which explain the grounds of the rule of law, by highlighting the different formal and substantive interpretations. This philosophical-historical analysis is complemented by a reconstruction of how the notion of the rule of law was developed by the international community, with a view to searching a common notion at the international level by comparing theory and practice within the main international organisations such as the UN, OECD and the Council of Europe. Specific mention is made of the EU experience, whose configuration as a Community based on the rule of law is often debated, starting from the case law of the European Court of Justice. The second chapter deals with the conditionality policy and focuses on the development and scope of democratic conditionality according to the dominant approach of the doctrine. First, the birth of conditionality is analysed from an economic point of view, especially within international financial organisations and the different types of conditionality recreated in the scientific sector. Then an analysis is provided about the birth of democratic conditionality in the EC – in relation to its external relations – firstly as a mere political exercise to be then turned into a standardised system of clauses. Specific reference is made to the main scope of conditionality, that is to say enlargement policy and the development of the Copenhagen criteria. The third chapter provides further details about the legal questions connected to the use of democratic clauses: on the one hand, the power of the EC to include human rights clauses in international agreements, on the other, the variety and overlapping in the use of the legal basis. The chapter ends with an analysis of the measures of suspension of agreements with third countries in those rare but significant cases in which the suspension clause, included in the Lomè Convention first and in the Cotonou Agreement then, is applied. The last chapter is devoted to the analysis of democratic clauses in unilateral acts adopted by the European Union which affect third countries. The examination of this practice and the comparison with the approach analysed in the previous chapter entails a major theoretical question. It is the clear-cut distinction between conditionality and international sanction. This distinction is to be taken into account when considering the premises and consequences, in terms of legal relations, which are generated when democratic clauses are not complied with. The chapter ends with a brief analysis of what, according to the reconstruction suggested, can be rightly labelled as real democratic conditionality, that is to say the system of incentives, positive measures developed within the community GSP. The dissertation ends with a few general considerations about the difficulties experienced by the EU in promoting the rule of law. The contradictory aspects of the EU external actions are manifold, as well as its difficulties in choosing the most appropriate measures to be taken which, however, reflect all the repercussions and tension resulting from the balance of power within the international community. The thesis argues that it is difficult to grant full credibility to an entity like the EU which, although it proclaims itself as the guardian and promoter of the rule of law, in practice, is too often biased in managing its relations with third countries. However, she adds, we must acknowledge that the EU is committed and constantly strives towards identifying new spaces and strategies of action.

Il principio di precauzione in diritto penale

Oggetto della ricerca è la rilevanza nell’ambito del diritto penale del principio di precauzione. Quest’ultimo deve la sua diffusione e popolarità al fatto di presentarsi come criterio guida al problema del rischio e dell’incertezza. L’esigenza di adottare scelte normative in condizioni di incertezza scientifica è infatti oggi ineludibile. Si cercherà in primo luogo di circoscrivere l’oggetto dell’indagine analizzando il rilievo che il principio di precauzione ha a livello legislativo e giurisprudenziale. Quindi si analizzeranno le problematiche che il ricorso allo stesso suscita con riferimento alla struttura classica del reato e legate al contesto di incertezza nel quale viene invocato. Tali problematiche si riferiscono alla possibilità o meno di dare rilevanza al modello del reato di pericolo, alla ricostruzione del nesso causale e all’influenza che il principio di precauzione può determinare nell’accertamento dell’elemento soggettivo delle colpa. Si concluderà l’analisi analizzando le diverse posizioni assunte dalla dottrina italiana circa l’opportunità o meno dell’intervento penale in contesti di incertezza scientifica, individuando, in caso di risposta affermativa, le modalità di intervento.

Il diritto d'asilo in Austria: il ruolo dell'interprete nelle richieste di protezione internazionale

Meine Diplomarbeit beschäftigt sich mit den Themen des Asylverfahrens in Österreich sowie mit der Rolle von DolmetscherInnen im Asylbereich; sie besteht aus der Übersetzung von Teilen einiger Lernmodule des Trainingshandbuchs, das 2015 von UNHCR Österreich herausgegeben wurde, sowie aus meinen Kommentaren. In den ersten Kapiteln werden die Voraussetzungen für einen Asylantrag, die Richtlinie der Europäischen Union und die Bundesgesetze bezüglich des Asylrechts sowie die Rolle der UNHCR erläutert. Es werden dann spezifisch das Asylverfahren in Österreich, die Phasen der Einvernahme mit den Behörden und die Rolle der DolmetscherInnen - mit Blick auf die Auswahl von DolmetscherInnen und die dazu erforderlichen Kompetenzen - analysiert. Darauffolgend werden die Themen von der Haftung der DolmetscherInnen und dem Risiko von einer Traumatisierung für die Sprachmittler sowie das Dolmetschen für vulnerable AntragstellerInnen angesprochen. Zuletzt vertieft meine Arbeit die ethischen Prinzipien für das Dolmetschen im Asylverfahren und analysiert, anhand von konkreten Beispielen, die Probleme, die sich aus den berufsethischen Anforderungen an DolmetscherInnen ergeben. Schließlich wird die Komplexität des Dolmetschens im Asylbereich hervorgehoben.